Our CNS Advisor, Carrie Riccobono, Reflects on New Breast Cancer Screening Guidelines (Part 2)
20 Jan 2017
This is Part 2 of Carrie’s series on the new breast cancer screening guidelines. In Part 1, she explained why breast exams are still important, and why self exams are crucial for women under age forty. She also covered mammograms during pregnancy and breastfeeding, and touched on the lack of context in detection and in radiology expertise. We’re so grateful to Carrie for taking the time to write these incredibly informative articles for us! You can read more about her here.
Under the Affordable Care Act (ACA), health plans are required to cover preventive services that are recommended by the U.S. Preventive Services Task Force (USPSTF), a nonpartisan group of medical experts (unfortunately, NO breast cancer experts are on the panel), without charging consumers anything out of pocket. The only exception is for plans that have grandfathered status under the law.
The task force’s breast cancer screening guidelines that are under consideration are slightly different than those from the American Cancer Society, and far more concerning.
Concerns About Task Force’s Breast Cancer Screening Guidelines
The task force recommends screening mammograms for women at average risk every two years starting at age fifty and continuing until age seventy four. I’m not sure about you, but I know many vibrant 75-year-old women that have a good twenty years of life to live. If these recommendations are finalized, some of these women would not be guaranteed full coverage of the screening without cost-sharing. We were successful working with congress to pass S. 1926/H.R. 3339, the Protect Access to Lifesaving Screenings (PALS) Act, to ensure access to screening mammograms. Congress has wisely imposed a temporary two-year moratorium on implementation of changes to the coverage of mammography services that would deprive most women in their forties of coverage.
If women choose to follow the USPSTF guidelines instead of the previously stated American Cancer Society guidelines (yearly mammogram beginning at age forty), approximately 6,500 more women will die of breast cancer each year (see Hendrick & Helvie’s 2011 study)!
SUMMARY OF ISSUES WITH USPSTF RECOMMENDATIONS. THEY DID NOT:
- Include any of the organized screening data from around the world.
- Include any breast cancer professionals on the Task Force.
- Calculate harm-to-benefit ratio (value judgment!).
The Task Force’s recommendations against better coverage of diagnostic mammography are in part a consequence of its procedural tendencies and in part a consequence of misunderstanding and misapplying the available data.
Poor Recommendations: A Result of Vague “False Positive” Concerns
The problem began in 2009, when the Task Force made a dramatic change in screening policy, recommending that asymptomatic women without risk factors aged 40-49 years should no longer be screened and that, beginning at age fifty, women should only be screened every other year. This recommendation was made with little consideration of randomized controlled trials (the single, most reliable, unbiased data source) that demonstrate lives are saved by beginning screening at age forty.
The recommendation was made despite the fact that forty percent of life years lost to breast cancer are attributable to women diagnosed in their forties and that the breast cancers that occur in women under the age of fifty are often the most aggressive. It ignored a major analysis demonstrating that approximately 100,000 women currently in their thirties would have their lives saved by beginning screening at age forty. And it ignored data demonstrating a threefold higher risk of breast cancer for women in their forties versus women in their thirties. How could this happen?
False Positives Argument Based On Questionable Data
The recommendation was justified in major part based on the alleged “harms” of screening. In particular, the Task Force focused on what it called “false positives”—a vague term it used to describe the ten percent of women who, based on older screening technology, used to be recalled for follow-up. Let’s not forget they used data from ALL radiologists, including general diagnostic radiologists in addition to breast-imaging specialists. Remember earlier (last two paragraphs of Part 1) when I talked about the different levels of breast-imaging expertise between radiologists? Some radiologists who may only infrequently read mammograms and who may be less comfortable with them may be more likely to call you back for additional images. Know WHO is behind your mammogram.
The Task Force badly misconstrued the supposed harm of such recalls. For fifty six percent of these women, all that is needed is an ultrasound or a few additional mammographic views to confirm the absence of cancer. For another twenty five percent, a precautionary follow-up in six months will be recommended. And for nineteen percent, a needle biopsy with local anesthetic will be undertaken, and, of those, six percent of women will have cancer detected and thus treated at an early stage when the prospects for success are greatest. This is a medically and statistically significant rate of detection and treatment. Congress has the power to override the USPSTF again—and I pray they do.
Given widespread criticism of the Task Force’s methodology and evidence evaluation, Congress was ultimately required to step in and block the 2009 recommendation from affecting insurance coverage. In 2015, however, the Task Force nonetheless reaffirmed its prior recommendation and finalized that position in February of 2016. In doing so it relied on the same flawed information.
Experts Weigh In, Plus, Key Points Regarding the Breast Cancer Screening Guidelines
Dr. Tabar, a world respected radiologist and breast cancer expert gave an excellent talk on early detection in Montreal in 2014. I would appreciate you reviewing his forty minute lecture and helping me understand why the mass media continues to report that mammograms do not save lives. Dr. Tabar explains how early detection (especially prior to lymph node involvement) has a direct impact on a patient’s quality of life, mortality and the types of surgeries and systemic treatments that may be needed.
The American College of Radiology has also weighed in in this press release.
Key Points Regarding the New Guidelines
I went to my connection at the American Cancer Society, and asked what key points they have regarding the new guidelines. I feel the media has caused some mass hysteria compounding on the USPTF saga—although in this case good hysteria . . . It would be good to keep the conversation happening. From my ACS contact:
- The guideline confirms that screening mammography is the most effective way for a woman to reduce the likelihood of dying prematurely from breast cancer.
- The guideline recognizes that a “one size fits all’ recommendation for women at average risk for breast cancer is not supported by the evidence. The guidelines balance a woman’s age and health and they also make room for personal preferences.
- Mammography is beneficial beginning at age forty and women should have the opportunity to balance the potential to reduce death from breast cancer with the possibility of false positive imaging test, biopsies, and overdiagnosis.
- However, the evidence clearly supports starting annual screening at age 45. The lives saved from annual screening starting at age 45 outweigh the potential for false positive findings and overdiagnosis.
- Our guidelines are intended to help women make choices so they can decide what’s best for them, in consultation with their doctor.
- We believe that every woman who needs a mammogram should have access to one.
You can find more information in the New Breast Cancer Screening Guidelines FAQ section at Cancer.org, and here at Dr. Len’s blog (Dr. Len is the Deputy Chief Medical Officer of the American Cancer Society).
So If I still have your attention: My main message is please be proactive in your health care decisions. All this hysteria overemphasizes the risks of “false positive mammograms,” which according to mammography detractors results in additional (and unnecessary) testing and not to mention a boatload of stress. Although this may be true for some women, no one is answering the question of why are women feeling this stress. I think I know: We have poor standards in the United States for who is touching our women, interpreting their mammograms, etc . . . so OF COURSE our outcomes are going to be skewed. WHY have the MQSA standards not been revised? Why do we not have standards in the United States to ensure competent providers or benchmark outcomes?
My consensus: continue your self breast exams monthly, continue your annual mammograms, and continue seeing your doctor yearly for a good physical and clinical breast exam. Continue to fight and trust your gut if you feel something is wrong, and continue to celebrate and honor yourself. We get one chance in this world to live our best lives!
Here’s a little more fun reading for you: Assessing and Improving the Interpretation of Breast Images: Workshop Summary (2015).
We’re so pleased to have Carrie on our advisory board! You can read more about her here.
18 Oct 2017 - I'm Taking Charge - Life After Breast Cancer